leading change from the front line in afghanistan · leading change from the front line in...

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Leading Change From the Front LineIn

Afghanistan

USAID Health Care Improvement (HCI) ProjectUniversity Research Co., LLC

Center for Human Services

Mirwais Rahimzai MD, MBA, MPH (USA)

April 07, 2011- Amsterdam

USAID HEALTH CARE IMPROVEMENT PROJECT

Outline

• Brief Country Profile • What and Where • URC Activities at 4 Levels:

1) Hospital Level 2) Health Facility Level (BPHS)3) Community Level 4) National level

• Keeping Quality Improvement Understood and Active at Different Levels


Brief Country Profile

Population: About 25million

Maternal Mortality: 1,600/100,000 LB

Infant Mortality: 129/1,000 LB

Under 5 mortality: 191/1,000 LB

Fertility Rate: 6.3

CPR: 24% (Modern + Traditional)

BPHS: Coverage about 85% of the country

EPHS: Coverage about 60% of the country

Hemorrhage, Obstructed Labor, Sepsis, PIH

Asphyxia, Infection, LBW


HCI Goal in Afghanistan

To improve quality and outcomes of health care by adapting and applying modern methods of quality improvement (QI)

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533,518 out of 1,144,800 people in Balkh

477,677 out of 882,900 people in Kunduz

Seven Hospitals in Kabul. Estimated catchment is 3,449,800 out of approximately 4,000,000

Coverage in Herat 1064500

Coverage in Parwan 253200Coverage in

Bamyan 161970


Intervention Package - Maternal Newborn Care Collaborative-Afghanistan

Service level Phase One Phase Two

ANC: Birth preparedness/complication readiness; Tetanus; Iron/Folate

ANC: Screening, stabilization and referral for complications (prep-eclampsia and other)

Post-partum: Essential Maternal and Newborn Care; Danger sign recognition and care seeking

Post-partum: Screening, stabilization, and referralof maternal and newborn complications (sepsis, etc.)

Community

BPHS

Hospitals

ANC: Birth preparedness; Danger sign recognition, Tetanus

Birth/Post-partum: AMTSL/ENC; IP; maternal/newborn monitoring and discharge

Improve Prevention and early detection of PPHImprove prevention and management of Birth Asphyxia Improve maternal/newborn postnatal careImprove Medical records

ANC: Screening and management of pre-eclampsia/eclampsia

Birth/Post-partum: Partogram; IP ;complications management (hemorrhage, eclampsia, sepsis, newborn asphyxia and

LBW), FP (LAM; progestin-based oral contraceptives)

Maternal/neonatal sepsis Eclampsia/ preclampsiaTriage Obstrcuted labor …….

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Key Results from three Collaboratives

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Proportion of partographs completed (vital signs admission ; cervical dilation curve, fetal heart rate with a minimum of two

points recorded (1389)

Ham Saw Jaw Sara Asa Sun Miz Aqr Qaw Jadi DalwNumerator 4 13 23 26 31 70 94 94 97 111 107Denominator 100 100 100 100 100 100 100 100 100 120 120Proportion 4 13 23 26 31 70 94 94 97 93 89

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Numerator: # Of partograms completed in the last monthDenominator: Total # of partograph sampled (20) in the last month in hospitalSource of data: Partograph review Sites: 6 hospitals in Kabul Province

1. Partograph training for doctors and midwives byHospital trainers with support of HCI2. Monitoring (check of 20 partographrandomly in morning report by QI team and on duty trainer specialist and give the feed back)3. Put the partograph as 2nd page of patients file to prioritize partograph filling4. Use only partograph paper for normal delivery cases instead of bundle patients' fil

1 2

3 & 4


Proportion of births for which 3 AMTSL elements performed (Oxytocine given at 1st minute after delivery, Cord traction,

uterine fundal massage) (1389)


0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Numerator: # of births for which 3 AMTSL elements performed (Oxytocine given at 1st minute after delivery, Cord traction, uterine fundal massage) in monthDenominator: Total # of vaginal births within last monthSource of data: F4/Direct observationSites: 6 hospitals in Kabul Province (the imprvement work is implemented in 4 hospitals out of 6)

1. Provision of presyringes with Oxyby responsible (o midwife

2. Training of staf AMTSL importanc value by HCI

3. Ask the mother her uterine massain rash times whe midwife is busy

3

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Average compliance with resuscitation standards(1389)


0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Numerator: # of resuscitation standards met (total cumulative standards met for 10 simulation cases in monthDenominator: Total # of resuscitation standards (cumulative # standards for 10 simulated cases) in monthSource of data: Simulation (F5)Sites: 6 hospitals in Kabul Province (the improvement work is implemented

1. Training of staf HCI on newborn resuscitation stan

2. installation ofintercom systemamong neonatalward, delivery rooand Operation rooto inform the neodoctors and midw soon as the baby with Birth asphyx HCI

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Proportion of births in which newborn put to breast within first hour after birth (1389)


0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Numerator: # of deliveries in which newborn put to breast within first hour after birth in last monthDenominator: Total # of births within last monthSource of data: F4/Direct observationSites: 6 hospitals in Kabul Province



1.Tramsfer of mothe baby together to the post delivery roominstead of sending t to the neonatal ward2. To let the attenda complicated cases t the mothers (PPH aPre-eclampsia)3.Tansfer of mothewho delivered normafter 30 minutes to t delivery room (so th will take place)


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1


Proportion of mothers who were monitored post-partum according to standards (1389)

Ham

Saw Jaw Sar

a Asa Sun Miz Aqr Qaw

Jadi

Dalw

Numerator 19 10 18 5 19 33 35 26 48 79 59Denominator 100 100 100 100 100 100 100 100 100 120 120Proportion 19 10 18 5 19 33 35 26 48 66 49

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Numerator: # of mothers who were monitored for vital signs (temp, BP, RR, P), vaginal bleeding, and uterine firmness 30 minutes, after half an hour, one hour, two hour and six hour after birth in last monthDenominator: Total # of partogram sampled (20) in the last monthSource of data: Partograph review Sites: 6 hospitals in Kabul Province

1. Provision of PNatal monitorin protocol (specif maternal)2. Delay the new vaccine (BCG) hours' after delicompleting 6th post partum hou3. Transfer the file with her in Pdelivery room

1, 2 .3


CHWs monthly meeting at NK CHC

ANC/PNC Counseling simulation


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10ANC 31% 51% 60% 69% 76% 86%PNC 16% 24% 51% 56% 61% 78%

% of Average ANC & PNC Counseling at Dehdadi DH, Noor Khuda CHC and Sherabad BHC in Balkh Province

ANC

PNC

Date source: Direct Observation of ANC & PNC Counseling Components based on checklist during CHWs monthly meetings

USAID HEALTH CARE IMPROVEMENT PROJECTAssociates in Process Improvement (API)

Methodology


Basics of collaborative improvement

QI team

site

Site-level summaryQI team

LearningSession

representative

Site-level testing of changes and analysis of results

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

QI team

site

Collaborative-level sharing and synthesis of best practices

QI team

site

QI team

site

Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care


Keeping Quality Improvement Understood and Active at Different Levels

1- Assisted the MoPH develop strategy for improving quality in health care

2- Assisting the MoPH to establish a structure to implement and oversee

3- Partnering with others to educate

4- Spreading knowledge on quality and exposing leaders to best practices


===

Lead Change

Lead Change

MoPH Unit

Provinces

Quality Focal Point Quality Focal Point

Hospitals

HFs

Leader

QI teams QI teams

Improve…Advisors

SeniorMgmt

Community

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Challenges

• Low wages and therefore low commitment • Out of date/complicated admin procedure • Lack of female staff• Turn over of staff and implementing NGO• Lack of basic needs in HF (supplies, equipment)• Not matching reporting and monitoring system

to the extent of expanded services • Security


Thank you!

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